HIPPA RELEASE OF INFORMATION

Name:

Date of Birth:

I authorize the release of information including the diagnosis, medical examination, and claims information rendered to me. This information may be released to and/or my primary care physician:

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I do not want my information released to anyone other than myself and/or my primary care physician.

PHONE MESSAGES

Please call:

Home:

Work:

Cell:

Email:

The information provided above may be used by our office staff and an automated reminder call system.

This policy shall remain in effect until terminated by me in writing.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

Your information will be encrypted.